The Impact of Anesthesia Handovers

Current Research and Possible Solutions

By John Wang, T4Tulane University School of MedicineThe Impact of Anesthesia Handovers2011 annual meeting of the society of cardiovascular AnesthesiologistsThe Impact of Anesthetic Handover on Mortality and Morbity in Cardiac Surgery. Hudson c; Tran d; Dupuis J; McDonald B; Boodhwani M; Hudson JUniversity of Owttawa Heart Institute, Ottawa, Ontario, Canada Patients passed from one anesthesiologist to another during cardiac surgery had a 2.2 times higher risk of dying in the hospital

Patients who underwent handover also were 55% likelier to experience major morbidity, including heart attack and strokeRecent Patient Safety LiteratureShown increasing agreement that effective patient handover is critical to patient safety

Patient handover has been defined a research priority

Handovers in the field of anesthesia is particularly important

3 Qs that need to be addressedWhat is the current handover practice?

What constitutes a handover that contributes to the quality and safety of patient care?

How can clinicians be trained for and effectively supported during handover?Current Handover PracticeVariable, unstructured and error prone

Current Handover PracticeEnvironmental Factors causes distraction

Study done by Anwari JS.looking at handoffs between the anesthesiologists and postoperative recovery nurses32.6% of anesthesiologists attained maximum scores for the quality of verbal information40% involved preoperative status36.6% involved premedication20.7% involved operative details15% involved intra-operative course and complications

Anwari JS. Quality of handover to the postanaesthesia care unit nurse. Anaesthesia 2002; 57(5); 535-542Criteria for handovers that contributes to the quality and safety of patient careLiterature review of 400 relevant articles, led to the identification of seven primary functions for patient handoffs

Information processingStereotypical narrativesResilienceAccountabilitySocial interactionDistributed cognitionCultural normsPatterson ES & Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 52-61Criteria for handovers that contributes to the quality and safety of patient careLiterature review of 400 relevant articles, led to the identification of seven primary functions for patient handoffs

Conclusion:

Diversity of handoff measurement approaches lack consensus about primary purpose of a handoff as well as promising interventions to improve handoff processesSuggests that overall quality were predicted by 3 factors: Information transfer, shared understanding, and working atmospherePatterson ES & Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Joint Commission Journal on Quality and Patient Safety 2010; 36(2): 52-61Clinician Training in HandoversCurrently, 56% of departments provide guidelines for patient transfers to intensive therapy units, and only 14% for handover of anesthetized patients.Horn J, Bell D & Moss E. Handover of responsibility for the anaesthetised patient-opinion and practice. Anaesthesia 2004;59: 658-663Standardized Protocol: Two MethodsFirst approach: defines specific information content and order and generates handover protocols that are specific to the clinical setting.

Standardized Protocol: Two MethodsSecond approach: general interaction structures that do not define the exact content, but the topics to be covered and their order

Team ApproachPatient handover is not just a one-way transfer of information

Team ApproachIts involves shared cognition/shared decision making between health-care providers and an opportunity for collaborative cross-checking.

Patterson E, Woods D, Cook R et al. Collaborative cross-checking to enhance resilience. Cognition, Technology & Work 2007; 9:155-1622011 annual meeting of the society of cardiovascular AnesthesiologistsPilot Implementation of a Perioperative protocol to Guide Operating Room-to-Cardiac ICU Patient HandoffsPetrovic M; Aboumatar H; Martinez EMassachusetts General Hospital, Boston, MA, USA; JohnHopkins University, Baltimore, MD, USAProtocol introduced a Standardized, Structured, and reproducible approachKey members of the team must be present during the handoff, including the surgeon, the anesthesiologist and the receiving nurse and clinicianUsing discipline-specific checklists

2011 annual meeting of the society of cardiovascular AnesthesiologistsPilot Implementation of a Perioperative protocol to Guide Operating Room-to-Cardiac ICU Patient HandoffsPetrovic M; Aboumatar H; Martinez EMassachusetts General Hospital, Boston, MA, USA; JohnHopkins University, Baltimore, MD, USAPercentage of missed information in the surgery reports decreased from 26% to 16% (p=0.03)Percentage of missed information in the anesthesia reports showed no significant change 19% to 17% (p>0.05)ICU nurse satisfaction scores increased from 61% to 81%Overall: perioperative handoff changed from noisy, multitasking process to an orderly, audible exchange of information among all team members

ConclusionsHandovers have shown to have a negative impact on patient outcomesLack of formal training and formal systems in handoff situationsOverall quality of handovers predicted by 3 factors: Information transfer, shared understanding, and work atmosphereEvidence that team based approach shows promise